This article was originally published in Maclean's Magazine on June 17, 2002
Maclean's 2002 Health Report
Imagine for a moment that you're a smoker who's been meaning to quit a pack-a-day habit for a while now. Or, if you can't picture yourself as a nicotine addict, maybe your doctor has been after you to trim that Molson muscle around your expanding midriff. Perhaps your cholesterol is bad, or your blood pressure is high, you have diabetes, or you just can't seem to pry yourself off the couch. And let's face it, none of us is getting any younger, right? Now that you've identified a health risk or two, consider what could happen. Would you know you were possibly about to die if suddenly you felt dizzy and your vision blurred? How about if you experienced an abrupt weakness, numbness or tingling in the face, arm or leg, had trouble speaking, or got a severe headache out of the blue? In a few cases you might shrug it off, lie down and hope the discomfort passes.
Not a good idea. You'd be ignoring the warnings signs associated with a stroke, says Maureen McKeen, director of health protection and promotion at the County-City Health Unit in Peterborough, Ont. "You don't just kind of wait around and self-diagnose, or say maybe it's nothing," cautions McKeen. "Often, we go into denial, but we should let somebody who knows make the diagnosis."
Making the right call isn't easy if you don't know the vital signs. The same can be said about the challenges besetting the 54 centres across Canada included in this year's fourth annual Maclean's ranking of health-care services. If we don't know how the system is functioning, how can anyone ever hope to fix it? Hard numbers help, including this year, for the first time, data from the Canadian Institute for Health Information (CIHI) on where Canadians are most likely to survive a stroke. The ranking casts a wide net, from the densely populated urban centres blessed with superb teaching hospitals to vast rural regions with few specialized services. The charts on the following pages rank the regions according to their performance in 22 indicators of proficient health-care delivery.
These findings, comparing the services available to more than 87 per cent of Canadians, give medical professionals, patients and their families an opportunity to take stock and compare how their regions measure up to the rest of the country. Given the health-care system's enormous complexities, and its differences from province to province, community to community, it isn't always immediately obvious why one region is performing better than another. The trick, though, is to identify problem areas, then dissect them.
This year's ranking, as in previous years, divides the health regions into three categories. Group 1 includes the 15 centres that benefit from the advantages associated with being home to a medical school. Several - Vancouver/Richmond, Toronto and Montreal among them - are comprised entirely of the cities giving them their names. But most of them include significant surrounding rural territory, which presents a greater challenge in terms of service delivery. Edmonton is just such a place, and for the fourth straight year the Alberta capital and its environs lead Group 1. Overall, the region ties for second place among the 54, up from fourth last year.
Prospects for improving further still are good, says Sheila Weatherill, chief executive of Edmonton's Capital Health Authority. The region's excellent showing came despite its dismal, 52nd-place finish in the category counting newborns with low birth weights. Edmonton has significant pockets of low-income households and a large aboriginal population, says Weatherill, two factors that contribute to higher rates of underweight babies. But a retargeting of health services at those groups has reduced the percentage from 6.4 per cent of births to 5.9 per cent, she says. Which is not to suggest everything else is fine. "Once you're in the system here, the care is good," Weatherill says, "but people do wait too long in many cases."
Edmonton stands out for another reason, one which may have caught the attention of the Commission on the Future of Health Care in Canada. In May, Weatherill made her case to commissioner Roy Romanow, arguing Edmonton's success in organizing all health-care services under one regional board, as opposed to organizing by specific services. One board then makes all the calls. "You focus resources better," says Weatherill, "and you reduce duplication and competition."
The group of communities with medical schools - featuring the best and brightest, latest and greatest - remains a powerhouse this year, with 13 out of 15 placing in the top half of all regions. Within Group 1, Halifax/Dartmouth made major gains, climbing nine places to rank 17th overall. Vancouver/Richmond and Calgary, however, slipped significantly, in part because of their low standings under two indicators new this year: the numbers of women receiving mammograms and Pap smears.
The results for Group 2 show that affluent suburbs and satellite communities remain among the best places to get sick. Many have impressive health-care centres of their own, bolstered by the services available in large urban facilities just a short ambulance ride away. For the third year running, North/West Vancouver, the affluent neighbour to the north of Vancouver, leads not only the 19 major urban centres in Group 2 but finishes first overall. Among its strengths: the life expectancy of its residents, few low-weight births and success in preventing unnecessary hospital admissions by having patients treated in doctors' offices or clinics.
Victoria and the Mississauga/Brampton/Burlington region bordering Toronto finish second and third in Group 2, reversing their standing of a year ago. (Their overall scores have been so close both years that they - like many regions separated by a ranking point or two - are virtually tied.) Three other Ontario regions - Windsor/Sarnia, Brantford and Peterborough - advance at least seven places this year. Although most of Group 2 finishes in the middle of the overall ranking, four Quebec regions rank lower - between 38th and 51st place.
But as in earlier years, it is the largely rural regions, relatively far from the modern equipment and highly trained specialists in the major centres, that dominate the bottom end of the overall ranking. Among the 20 in Group 3, only two B.C. regions - Kelowna (a remarkable fifth overall) and Nanaimo (23rd) - make their way into the top half of the rankings. Holding down the bottom three spots are Sudbury, Ont., North Bay/Huntsville, Ont., and - dead last in 54th spot - Prince George, B.C.
The trick now is for each region, regardless of ranking, to find ways to address its weaknesses, says CIHI chairman Michael Decter. It's up to the medical community to examine the data and determine what needs doing. "The goal here isn't to award a prize to the best region," says Decter. "It is to shift the whole performance curve in a positive direction."
Health care eats through sacks of dough - more now than ever. In 2001, CIHI notes in its annual "Health Care in Canada" report, Canadians passed the $100-billion barrier, spending $102.5 billion on private and public medical treatment and services. Up 4.3 per cent from the previous year, that's about $3,300 for every living - and dying - Canadian. Hospitals accounted for 32 per cent of the spending, drugs 15 per cent and doctors 14 per cent. In 2000, health-care expenses accounted for 32 per cent of spending by the provinces and territories, up from 27 per cent in 1975.
Medication costs are worrisome. Last year, Canadians spent about $15.5 billion on retail drugs, up 8.6 per cent from 2000, or just over $500 per person. Among the industrialized nations, only the United States, France, Japan and Belgium spend more. The burden is greatest for the lowest income households in Canada. They spend more on health care, as a percentage of family income, than do the richest households: 3.9 per cent versus 2.6 per cent. But for all that spending, one in eight Canadians said their health-care needs were not met in fiscal year 2000-2001, a substantial increase from one in 17 in 1998-1999. A common complaint: long waits for care.
In some cases, there just aren't enough doctors to go around. By numbers alone, there would seem to be about as many physicians as ever, says Dr. Ben Chan, a senior scientist at the Institute for Clinical Evaluative Sciences in Toronto. But in a study of physician numbers throughout the 1990s, prepared for CIHI and released last week, Chan notes that an aging population is placing higher demands on doctors. At the same time, he reports, more physicians are women, who typically work about one-fifth fewer hours than their male counterparts. Taking these two factors into account, Chan noted the ratio of doctors to the general population peaked in 1993, and has since fallen five per cent. The main reason for the decline, Chan says, is that doctors are spending more time training, so they're not on the front lines as quickly as they used to be. The proportion of graduates who become general or family practitioners also dropped sharply in the past decade, from a high of 80 per cent in 1992 to just 45 per cent in 2000.
Chan challenges the common belief that cuts to medical-school enrolments in the early '90s are the main cause of current shortages. Those cuts played a role, he says, but other factors - namely the longer training times, fewer foreign doctors entering Canada and more physicians retiring - had bigger impacts. Canada's practice of mounting major health-care planning initiatives only every eight to 10 years should be re-examined, Chan says. He believes trends need to be monitored more frequently, and changes made more quickly to adjust doctor numbers. "It's very difficult to predict the future - you're always going to be a little too high or too low," says Chan. "But we should be trying to do a better job of smoothing out the bumps."
Getting the provinces to supply health-care data is a little like herding cats - each one wants to head off in its own direction. That leads to gaps in information. British Columbia and Quebec, for instance, gather research on heart attacks and strokes differently than other provinces, so their numbers cannot be included in CIHI's national data. CIHI also has no numbers for heart attacks in Newfoundland and Labrador. And while several provinces track how long patients wait in emergency rooms for a hospital bed, only Ontario, Nova Scotia and New Brunswick supplied CIHI with their findings. That hardly makes for a national picture, but for what it's worth: 80 per cent of people admitted in those three provinces waited less than six hours for a bed. Three per cent waited longer than 24 hours - becoming part of those periodic back-ups of patients on gurneys in Emerg that create headlines.
CIHI is working on collecting better wait-time data, says Jennifer Zelmer, the institute's director of health reports and analysis. It often comes down to getting all the provinces to count things the same way. Waits for bypass surgery, for instance. "When do you start the clock?" asks Zelmer. "When the first symptoms appear? When you first see your GP? Or when you first meet with a specialist?"
The provinces are beginning to get the message. Alberta promises to change in at least one regard. "We will be trying to work on a common definition of when wait times start and stop so we can compare them across Canada," says Gary Mar, the province's minister of health and wellness. The ball is already rolling. At a first ministers' conference in Ottawa in September, 2000, the premiers agreed to harmonize how provinces track 14 medically important factors, including life expectancy, infant mortality and waiting times for key diagnostic and treatment services. The first standardized reports on these indicators are due in September. It's an encouraging first step toward a truly national snapshot, says CIHI's Decter. "Over time, we hope to get there," he says. "It depends on the goodwill of each province."
A close look at an individual region's results illustrates how the rankings can shift from year to year. Peterborough's, for example. The city and its largely rural surroundings, home to 130,000 Ontarians, gained an impressive seven places from last year, landing in the middle of the pack at 28th place overall. In part, that's due to the inclusion this year of data that CIHI and Statistics Canada have gathered for the first time on several new health-care indicators. Peterborough, it turns out, does exceptionally well coping with stroke, as measured by the numbers who die within 30 days of being hospitalized. McKeen at the County-City Health Unit thinks Peterborough's fourth-place score may have to do with the region's comprehensive campaign to raise awareness of heart and stroke issues. "It's reassuring," says McKeen, "to think that the road we've been on - working with other community partners - is the right way to go."
The Eastern Region of Newfoundland, on the other hand, shows what happens when resources are stretched to the limit. The sprawling rural jurisdiction, just west of the St. John's region, has too few residents to be included in the Maclean's ranking. CIHI's data, however, show it to be noteworthy for one staggering finding. Of its people hospitalized for stroke, more than one third die within 30 days - the highest mortality rate among the 36 regions that CIHI cited in that category. "The figures are not surprising," says Dr. Catherine Donovan, the area's medical officer of health, "but they're disturbing." Hardly a day goes by when she isn't trying to convince others of the need to spend on public education. Money is scarce and the benefits of raising awareness would likely be seen only 20 years from now, says Donovan, but it is essential. "Somebody," she says, "has to have the courage to put that investment in there now."
The reasons for specific results in specific regions are myriad. Why, for instance, would Vancouver/Richmond do poorly in providing Pap smears? According to a recent study by the B.C. Cancer Agency, women in the region's large Chinese community are less likely to have themselves tested than women in the general population. Dr. John Blatherwick, chief medical health officer for the Vancouver Coastal Health Authority, says the behaviour seems to be culturally rooted, with Chinese women more reluctant to be examined by a male physician. "We may have become complacent," says Blatherwick, "in not doing more public education." That seems to be changing. "We're trying to develop culturally appropriate materials that will be sensitive," says Dr. Greg Hislop at the B.C. Cancer Agency, "to facilitate going for Pap testing within different communities."
Even when things go right they can go wrong. Nova Scotia has one of the best ground and air ambulance services in North America. Yet the Yarmouth/Digby region in the southwest of the province is one of those disadvantaged rural areas, ranking 45th overall. In terms of stroke survival, it places 31st - better than in many other categories, but still a sign of negative factors at play. Smoking, education levels and obesity tend to be a problem in the area, says Morris Green, a spokesman in Nova Scotia's health department. So no matter how fast an ambulance arrives, it won't help if it's been called too late, or the person is so sick there isn't much that can be done to help. "The good news," says Green, "is we are aware of it." Now the provincial health department will work with the Heart and Stroke Foundation of Nova Scotia to develop an integrated stroke strategy, including province-wide standards for care, treatment and better public education. "Certainly," says Green, "the anecdotal evidence suggests that in some parts of the province, a lot of people don't know the warning signs."
So once again, it's back to training people to do more to help themselves. Heart disease and stroke are bad news, accounting for one in five men and a little more than one in 10 women admitted to hospital. What to do about it? The same old advice: eat better, exercise more, quit smoking. Some Canadians are taking heed, judging by a StatsCan survey in seven provinces and the Yukon. About half of adults and teens said they'd acted in the past year to improve their health - more physical activity, losing weight, changing diet, cutting back or quitting cigarettes. Several provincial efforts to reduce the numbers of people with flu clogging emergency rooms seem to be working. In 2000-2001, 27 per cent of Canadians over the age of 11 got a flu shot, almost doubled from 1996-1997.
One way of improving health care is to take a relative few physicians or facilities that are good at something and have them do more of it. Take knee surgery. Seven in 10 knee replacements in 1999-2000 were performed in hospitals doing more than 100 a year, but almost seven per cent - more than 1,400 cases - were in hospitals doing fewer than 50 a year. For many types of care, CIHI reports, research shows patients treated in hospitals that perform the procedure frequently are less likely to experience complications or to die after surgery. Obviously, medical practice makes, if not perfect, certainly better.
Alberta's Mar promotes the idea of concentrating certain services to improve outcomes and save money. "Some of the best pediatric cardiac surgery in Canada is done in Edmonton," says Mar, citing the city as a centre for the Prairies region. "Does it make sense for Saskatoon or Regina to have a similar type of pediatric cardiac surgery? No, I don't think it does."
But which surgeries do you target? It can become a delicate balancing act, risking hurt to institutional, community and even provincial pride. There are trade-offs, says Decter. While it isn't necessarily desirable to have a pregnant woman travel great distances, that may be best in the event of complications. "The idea isn't to have one giant hospital in downtown Toronto doing all surgeries," says Decter. "There are a lot of surgeries that should be done close to home because there's enough volume. It comes down to: can we manage the system more on the data and the evidence, rather than on history and tradition?"
Critics could argue that because of gaps in the data, the Maclean's ranking doesn't truly reflect what is going on across the country. True, the picture is incomplete. But it's the best one we've got, and it's getting clearer every year. Five years ago a ranking simply couldn't have been done. "There was no comparable data, in which case everyone thinks they're doing a terrific job unless you've got blatantly visible quality problems," says Decter. Now, CIHI distributes a growing body of data, allowing health authorities to compare their performances. "People can ask themselves if they should be concerned that they're maybe one or two per cent worse than some other hospital," says Decter. "What we're doing is providing the basis for a lot of questions to get asked - and eventually answered." It's a giant step in the right direction.
Taking Care of Strokes
The best survival rates four weeks after hospital admission for a new stroke:
4. Owen Sound, Ont.
6. Kitchener/Waterloo, Ont.
7. Mississauga/Brampton/Burlington, Ont.
8. Markham/Richmond Hill, Ont.
9. Peterborough, Ont.
10. Thunder Bay, Ont.
(Includes health regions over 125,000 pop. Data notavailable for B.C. and Quebec)
Watching for Breast Cancer
Who's giving the most mammograms?
1. Windsor/Sarnia, Ont.
2. Longeuil/Brossard/Granby, Que.
4.* Nanaimo, B.C.
Markham/Richmond Hill, Ont.
On Guard Against Cervical Cancer
Who's giving the most Pap smears?
4 Peterborough, Ont.
5* Kelowna, B.C.
(* indicates a tie. Includes health regions over 125,000 pop.)
Maclean's June 17, 2002